St Andrew's COVID-19 surgery safety study: hand trauma.

INTRODUCTION: Adaptation is vital to ensure successful healthcare recovery during the COVID-19 pandemic. Hand trauma represents the most common acute emergency department presentation internationally. This study prospectively evaluates the COVID-19 related patient risk, when undergoing management within one of the largest specialist tertiary referral centres in Europe, which rapidly implemented national COVID-19 safety guidelines. MATERIALS AND METHODS: A prospective cohort study was undertaken in all patients referred to the integrated hand trauma service, during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. Random selection was undertaken for patients with hand trauma who either underwent non-operative (control group) or operative (surgery group) management; these groups were prospectively followed-up within a controlled cohort study design and telephoned at 30 days following first intervention (control group) or postoperatively (surgery group). RESULTS: Of 731 referred patients (566 operations), there were no COVID-19 related deaths. Both groups were matched for sex, age, ethnicity, body mass index, comorbidities, smoking, preoperative/first assessment COVID-19 symptoms, pre- and postoperative/first assessment isolation and positive COVID-19 contact (p > 0.050). There were no differences in high service satisfaction (10/10 compared with 10/10; p = 0.067) and treatment outcome (10/10 compared with 10/10; p = 0.961) scores, postoperative/first assessment symptoms (1%, 1/100 compared with 0.8%, 2/250; p = 1.000) or proportion of positive tests (7.1%, 1/14 compared with 2.2%, 2/92; p = 0.349), between the control (n = 100) and surgery (n = 250) groups. CONCLUSION: These data support continued and safe service provision and no increased risk to patients who require surgical management. Such findings are vital for healthcare providers when considering service adaptations to reinstate patient treatment.

St Andrew's COVID-19 Surgery Safety (StACS) study: Skin cancer.

BACKGROUND: Skin cancer represents the most common malignancy worldwide and it is imperative that we develop strategies to ensure safe and sustained delivery of cancer care which are resilient to the ongoing impact of COVID-19. OBJECTIVE: This study prospectively evaluates the COVID-19 related patient risk and skin cancer management at a single tertiary referral centre, which rapidly implemented national COVID-19 safety guidelines. METHOD: A prospective cohort study was performed in all patients who underwent surgery for elective skin cancer service management, during the UK COVID-19 pandemic peak (April-May 2020). 'Real-time' 30-day hospital database deceased data were collected. Random selection was undertaken for patients who either underwent operative (surgery group) management or remained on the waiting list (control group); these groups were also prospectively followed-up within a controlled cohort study design and telephoned at the end of June 2020 for the control group or 30 days post-operatively. RESULTS: Of the 767 patients who had operations, there were no COVID-19 related deaths. Both the surgery (n = 384) and control (n = 100) groups were matched for age, sex, ethnicity, BMI, presence of comorbidities, smoking and positive COVID-19 contact. There were no differences in post-operative versus any symptom development (1.3%, 5/384 vs. 4%, 4/100, p = 0.093), or proportion of positive tests (8.6%, 33/384 vs. 8%, 8/100; p = 0.849), between the surgery and control groups. CONCLUSION: These data support continued and safe service provision, and no increased risk to skin cancer patients who require surgical management, which is vital for continuation of cancer treatment in the context of a pandemic. LEVEL OF EVIDENCE: II.

St Andrew's COVID-19 surgery safety (StACS) study: Elective plastic surgery, trauma & burns.

INTRODUCTION: This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines. METHOD: A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group). RESULTS: Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236). CONCLUSION: We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

Maternal and neonatal effects of Acinetobacter colonisation in preterm premature rupture of membrane and term labour.

INTRODUCTION: Some anecdotal reports suggest that maternal colonisation with Acinetobacter baumannii during pregnancy is associated with adverse maternal and neonatal effects, including preterm premature rupture of membrane (PPROM). The objective of this study was to compare the maternal and neonatal effects of A. baumannii colonisation in cases with PPROM and those with spontaneous onset of labour at term. METHODS: The recruitment of participants' was carried out at Selayang Hospital, Selangor, Malaysia. Vaginal swabs were prospectively taken from 104 patients of PPROM and 111 with spontaneous onset of labour at term. Swabs were also taken from the axillae and ears of their babies. These swabs were cultured to isolate A. baumannii. Maternal and neonatal adverse outcomes were documented. RESULTS: Sixteen mothers were A. baumannii positive, eight from each group respectively. None of the cases developed chorioamnionitis or sepsis. Those positive were four cases of PPROM and two babies of term labour. None of the babies developed sepsis. CONCLUSIONS: This study does not support the suggestion that A. baumannii colonisation during pregnancy is associated with adverse maternal and neonatal outcomes.

Physical comorbidity in schizophrenia & its correlates.

The presence of common physical comorbidities, their demographic and clinical correlates and impact on functioning was assessed in 100 patients with schizophrenia. The patients had a mean age of 35.12±10.7 yr with mean duration of illness of 8.3±0.58 years. Seventy per cent were detected to have a comorbid physical condition. Common conditions included hypertension (21%), diabetes mellitus (15%) and anaemia (12%). Increasing age, being female, being married, longer duration of illness and longer duration of treatment were associated with higher risk of having a comorbid physical illness. Further studies need to be done with a large sample to confirm these findings.

An ANMS-NASPGHAN consensus document on anorectal and colonic manometry in children.

BACKGROUND: Over the last few years, the study of the colon and anorectal function has experienced great technical advances that have facilitated the performance of the tests and have allowed a more detailed characterization of reflexes and motor patterns. As a result, we have achieved a much better understanding of the pathophysiology of children with defecation problems. Anorectal and colonic manometry are now commonly used in all major pediatric referral centers as diagnostic tools and to guide the management of children with intractable constipation and fecal incontinence, particularly when a surgical intervention is being considered. PURPOSE: This review highlights some of the recent advances in pediatric colon and anorectal motility testing including indications and preparation for the studies, and how to perform and interpret the tests. This update has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN).

Plasma-induced signatures reveal an extracellular milieu possessing an immunoregulatory bias in treatment-naive paediatric inflammatory bowel disease.

The inflammatory state associated with Crohn's disease (CD) and ulcerative colitis (UC) remains incompletely defined. To understand more clearly the extracellular milieu associated with inflammatory bowel disease (IBD), we employed a bioassay whereby plasma of treatment naive paediatric IBD patients (n = 22 CD, n = 15 UC) and unrelated healthy controls (uHC, n = 10) were used to induce transcriptional responses in a healthy leucocyte population. After culture, gene expression was measured comprehensively with microarrays and analysed. Relative to uHC, plasma of CD and UC patients induced distinct responses consisting, respectively, of 985 and 895 regulated transcripts [|log2 ratio| ≥ 0·5 (1·4-fold); false discovery rates (FDR) ≤ 0·01]. The CD:uHC and UC:uHC signatures shared a non-random, commonly regulated, intersection of 656 transcripts (χ(2)  = P < 0·001) and were highly correlative [Pearson's correlation coefficient = 0·96, 95% confidence interval (CI) = 0.96, 0.97]. Despite sharing common genetic susceptibility loci, the IBD signature correlated negatively with that driven by plasma of type 1 diabetes (T1D) patients (Pearson's correlation coefficient = -0·51). Ontological analyses revealed the presence of an immunoregulatory plasma milieu in IBD, as transcripts for cytokines/chemokines, receptors and signalling molecules consistent with immune activation were under-expressed relative to uHC and T1D plasma. Multiplex enzyme-linked immunosorbent assay (ELISA) and receptor blockade studies confirmed transforming growth factor (TGF)-ß and interleukin (IL)-10 as contributors to the IBD signature. Analysis of CD patient signatures detected a subset of transcripts associated with responsiveness to 6-mercaptopurine treatment. Through plasma-induced signature analysis, we have defined a unique, partially TGF-ß/IL-10-dependent immunoregulatory signature associated with IBD that may prove useful in predicting therapeutic responsiveness.

Excessive coupling of the salience network with intrinsic neurocognitive brain networks during rectal distension in adolescents with irritable bowel syndrome: a preliminary report.

BACKGROUND: The neural network mechanisms underlying visceral hypersensitivity in irritable bowel syndrome (IBS) are incompletely understood. It has been proposed that an intrinsic salience network plays an important role in chronic pain and IBS symptoms. Using neuroimaging, we examined brain responses to rectal distension in adolescent IBS patients, focusing on determining the alteration of salience network integrity in IBS and its functional implications in current theoretical frameworks. We hypothesized that (i) brain responses to visceral stimulation in adolescents are similar to those in adults, and (ii) IBS is associated with an altered salience network interaction with other neurocognitive networks, particularly the default mode network (DMN) and executive control network (ECN), as predicted by the theoretical models. METHODS: Irritable bowel syndrome patients and controls received subliminal and liminal rectal distension during imaging. Stimulus-induced brain activations were determined. Salience network integrity was evaluated by the functional connectivity of its seed regions activated by rectal distension in the insular and cingulate cortices. KEY RESULTS: Compared with controls, IBS patients demonstrated greater activation to rectal distension in neural structures of the homeostatic afferent and emotional arousal networks, especially the anterior cingulate and insular cortices. Greater brain responses to liminal vs subliminal distension were observed in both groups. Particularly, IBS is uniquely associated with an excessive coupling of the salience network with the DMN and ECN in their key frontal and parietal node areas. CONCLUSIONS & INFERENCES: Our study provided consistent evidence supporting the theoretical predictions of altered salience network functioning as a neuropathological mechanism of IBS symptoms.

Oral fluid testing as an alternative to urine testing for drugs of abuse in inpatient forensic settings: giving patients choice.

BACKGROUND AND AIMS: The abuse of illicit substances is very common amongst forensic psychiatry populations and is known to be one of the most potent risk factors for interpersonal violence. Forensic psychiatry units hence strive to keep themselves as free as possible from illicit substances and in Scotland drugs of abuse have traditionally been screened for by means of urine testing. The aim of this study is to examine patients' preferences for drug testing methods and to compare the acceptability of urine testing versus oral fluid testing (OFT) within a secure hospital setting. METHODS: Patients in three continuing care wards at the State Hospital, Carstairs were offered the choice of either urine or oral fluid testing. We developed protocols and recording forms and trained staff in the administration of the OFT. We recorded the sampling time for OFT and urine, and the views of patients and staff on the testing procedures over a six month period. RESULTS: Sixty-two samples were taken, with 53 (85%) opting for OFT and nine (15%) opting for urine sampling. The average time taken for OFT was 13 minutes, while the average time taken for urine sampling was 33 minutes. The majority of patients and staff rated oral fluid and urine testing as comfortable and easy. Patients recorded comments on 46 (87%) of OFT samples, only two of which were negative. In general they preferred the OFT because it was quicker and easier and they commented on it being more dignified and private. Patients recorded comments on five (55%) of urine samples, with one of the primary reasons for opting for urine sampling appearing to be a reluctance to try new things, though a few said they did not want to have anything in their mouths. Staff returned comments on 24 (45%) of OFT samples and one (11%) of urine samples. Comments on the OFT were overwhelmingly positive and pointed out the relative speed and ease of this sampling method. CONCLUSIONS: We concluded that the pilot study was successful. OFT was found to be generally preferred by patients and staff. Although there was an additional financial cost, this was considered to be outweighed by the significant benefits arising from offering patients choice, the preservation of patient dignity and staff time savings. The option of OFT has now been extended to all patients within the State Hospital. Practitioners will wish to consider the value of OFT in forensic psychiatry inpatient settings given the benefits identified within this study.

Validation of an instrument to measure quality of life in British children with inflammatory bowel disease.

OBJECTIVE: To validate IMPACT-III (UK), a health-related quality of life (HRQoL) instrument, in British children with inflammatory bowel disease (IBD). PATIENTS AND METHODS: One hundred six children and parents were invited to participate. IMPACT-III (UK) was validated by inspection by health professionals and children to assess face and content validity, factor analysis to determine optimum domain structure, use of Cronbach alpha coefficients to test internal reliability, ANOVA to assess discriminant validity, correlation with the Child Health Questionnaire to assess concurrent validity, and use of intraclass correlation coefficients to assess test-retest reliability. The independent samples t test was used to measure differences between sexes and age groups, and between paper and computerised versions of IMPACT-III (UK). RESULTS: IMPACT-III (UK) had good face and content validity. The most robust factor solution was a 5-domain structure: body image, embarrassment, energy, IBD symptoms, and worries/concerns about IBD, all of which demonstrated good internal reliability (α = 0.74-0.88). Discriminant validity was demonstrated by significant (P  < 0.05, P < 0.01) differences in HRQoL scores between the severe, moderate, and inactive/mild symptom severity groups for the embarrassment scale (63.7 vs 81.0 vs 81.2), IBD symptom scale (45.0 vs 64.2 vs 80.6), and the energy scale (46.4 vs 62.1 vs 77.7). Concurrent validity of IMPACT-III (UK) with comparable domains of the Child Health Questionnaire was confirmed. Test-retest reliability was confirmed with good intraclass correlation coefficients of 0.66 to 0.84. Paper and computer versions of IMPACT-III (UK) collected comparable scores, and there were no differences between the sexes and age groups. CONCLUSIONS: IMPACT-III (UK) appears to be a useful tool to measure HRQoL in British children with IBD.

Changing trends of services used as first contact by patients with mental health problems.

BACKGROUND: In the past, traditional faith healers and practitioners of alternative medicine have often been reported to be the first source of contact for Indian patients with mental health problems. However, over the past few decades, this trend seems to be changing. METHOD: Using a semi-structured questionnaire, we assessed 200 new patients at a psychiatric outpatient service in a general hospital for the first service contact used by them for their mental health problems. RESULTS: Psychiatrists, non-psychiatric physicians, traditional faith healers and practitioners of alternative medicine were the first service contact for 91 (45.5%), 88 (44%), 16 (8%) and 5 (2.5%) patients, respectively. Patients suffering from severe mental illnesses were more likely to choose a psychiatrist as the first contact, whereas those with neurotic, stress-related and organic mental disorders contacted a non-psychiatric physician. CONCLUSION: In the current scenario, psychiatrists and nonpsychiatric physicians serve as the first service contact for most patients with mental health problems in India, though traditional faith healers and practitioners of alternative medicine are contacted by a minority.

Muscle response during treatment of Class II Division 1 malocclusion with Forsus Fatigue Resistant Device.

PURPOSE: To evaluate the muscle response in order to determine the mechanism of neuromuscular adaptations with Forsus Fatigue Resistant Device which has greater elasticity and flexibility; allows greater range of movement of mandible; is available in prefabricated assembly of springs, tubes and rods and is a simple, effective and reliable corrective appliance that benefits not only growing patients but also malocclusions that previously required extractions, headgears and surgery. METHOD: Bilateral EMG activity from anterior temporalis and masseter muscles was monitored longitudinally on 10 young growing females with Class II Division 1 malocclusion to determine changes in postural, swallowing, and maximal voluntary clenching over an observation period of 6 months. RESULTS: There was a significant decrease in the muscle activity at one month after Forsus Fatigue Resistant Device insertion during swallowing of saliva and maximal voluntary clenching which gradually returned to pre treatment levels at the end of six months. CONCLUSION: This study suggests that Forsus Fatigue Resistant Device should be given for at least six months to allow for adequate neuromuscular adaptations to occur for long-term stability of the result.

Sodium thiosulfate-based treatment in calcific uremic arteriolopathy: a consecutive case series.

BACKGROUND: Calcific uremic arteriolopathy (CUA) is a rare complication in end stage renal disease with high mortality. Numerous case reports and one case series of 3 patients report the benefit of sodium thiosulfate (STS) for treatment of CUA. The purpose of this evaluation was to examine the response to a STS-based treatment approach in patients with CUA with 1 year follow up. METHODS: A retrospective case series of 6 consecutive patients from Manitoba, Canada who met predefined diagnostic criteria for CUA and received STS between 2006 and 2008 were included. STS responders were defined as improvement in at least one of the following three parameters: pain severity, wound size and diagnostic imaging/radiography. Mortality, STS dose, duration, adverse events and cost were also collected. RESULTS: Four patients were classified as responders. The 2 responders who survived at 1 year of follow-up demonstrated an improvement in all 3 parameters examined including an improvement in their follow-up diagnostic imaging results within the first 4 - 6 weeks of STS treatment. At 1 year of follow-up, 3 patients died. CONCLUSION: Using an STS-based multifaceted treatment approach for CUA, 4 patients responded but 3 of 6 patients died within 1 year. Further larger prospective studies are needed to delineate STS responders from non-responders.

The evaluation of a successful home hemodialysis program: establishing a prospective framework for quality.

A mounting body of clinical data and purported quality of life benefits has been primarily responsible for a renewed interest in programs providing longer more frequent home hemodialysis. As novel forms of home hemodialysis (HHD) like nocturnal (nightly) home hemodialysis (NHD) move from strictly the academic "experimental" arenas to potentially the preferred renal replacement modality for patients, it will be necessary for programs to plan and evaluate standardized metrics for program quality. This will be essential for smaller, less experienced centers to gauge their outcomes against larger, more established programs. Driven by market forces primarily in the United States, conventional hemodialysis programs have begun to explore optimal strategies for reporting quality of care in their respective dialysis centers. Extrapolating this to home hemodialysis modalities the question remains which criteria do we use as measures of quality? The evidence is limited to small, observational studies and one small randomized controlled trial. Extrapolating existing quality indices from conventional hemodialysis seems reasonable however may miss many of the true clinically significant advantages of HHD as a modality. Although definitive evidence does not yet exist for intensive home hemodialysis strategies, clearly clinicians, payers and patients are convinced enough of this approach for programs to justify the expansion of these modalities. We have laid the groundwork for the CANadian Slow Long nightly ExtEnded dialysis Programs (CAN-SLEEP), a multicenter cohort aimed to investigate the clinical and programmatic outcomes of NHD. This will allow for the assessment of numerous outcomes on a global scale for this state-of-the art dialysis modality in the form of a multidimensional programmatic evaluation.

Changing Pattern of Alcohol Abuse in the Army before and after AO 3&11/2001.

BACKGROUND: The Army Order 3&11/2001 was introduced to curb alcoholism and to weed out habitual alcoholics. Hence a study was carried out in a zonal referral hospital from 01 Jan 2001 to 30 Jun 2003 to assess its effectiveness. METHODS: The subjects consisted of officers, junior commisioned officers and other ranks who satisfied the International Classification of Diseases (ICD) 10 criteria for alcohol dependence. RESULT: Out of 1023 consecutive admissions, alcohol dependent cases numbered 245 (23.95%). They were disposed as under: 57/ 245 (23.6%) in S1 (fit for all duties), 67/245 (27.35%) in S2 (fit for duties with few restrictions), 72/245 (29.39%) in S3 (fit for duties with more restrictions), and 32/245 (13.06%) in S5 (unfit for further service.). CONCLUSION: The data showed that the percentage of cases disposed under fit for all duties had risen four times (23.80 vs 5.86), those invalided out increased by two times (12.70 vs 6.64) and those retained in S2 had reduced (26.46 vs 41.21) after the new policy.

The use of autologous chondrocyte implantation following and combined with anterior cruciate ligament reconstruction.

We report our experience of using autologous chondrocyte implantation (ACI) to treat osteochondral defects of the knee in combination with anterior cruciate ligament (ACL) reconstruction. The outcome of symptomatic osteochondral lesions treated with ACI following previous successful ACL reconstruction is also reviewed. Patients were followed for a mean of 23 months. Nine patients underwent ACL reconstruction in combination with ACI. Mean modified Cincinnati knee scores improved from 42 to 69 following surgery. Seven patients described their knee as better and two as the same. A second group of nine patients underwent ACI for symptomatic articular cartilage defects following previous ACL reconstruction. In this group, the mean modified Cincinnati knee score improved from 53 to 62 after surgery. Six patients described their knee as better and three as worse. Combined treatment using ACI with ACL reconstruction is technically feasible and resulted in sustained improvement in pain and function. The results following previous ACL reconstruction also resulted in clinical improvement, although results were not as good as following the combined procedure.